Rethinking Thin - Book Summary

Here’s a quick synopsis of Rethinking Thin for anyone who hasn’t had a chance to read it yet. We’d like to have everyone join in the discussions, so orient yourself here with our 3FC Cliff Notes and jump in!

The book weaves together the story of a weight loss study conducted at the University of Pennsylvania with chapters about the history of dieting and the evolution of the science of weight and obesity. It then ends with the author’s controversial conclusions about where science leaves us in the battle against obesity. Chapter by chapter, it looks like this:

Prologue

The prologue introduces us to the key questions to be explored in the book:

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The saga of people’s unending attempts to control their weight is a tale of science and society, of social mores and social sanctions, of politics and power. It raises questions of money and class, and of whether there is such a thing as free will when it comes to eating and body weight. It raises questions of how and why the discoveries of science, which have slowly chipped away at the reasons for obesity and the real health effects of being overweight, have been shunted aside by marketing and hucksterism and politics. (p 7)

Chapter 1: Looking for Diets in all the Wrong Places

The book opens with an introduction to Carmen Pirollo, one of a group of dieters enrolled in a two-year study at the University of Pennsylvania comparing Atkins with a traditional low-calorie diet. The study began at the height of the Atkins/low-carb mania and all the participants hoped to be randomly assigned to the Atkins group.

The chapter is a rundown on the specifics of the two diet plans. Atkins is straight Atkins and the low-calorie plan used was LEARN, a diet and behavioral modification plan written by Kelly Brownell of Yale’s Rudd Center for Food Policy and Obesity. As we all know, Atkins is most nutritionist’s nightmare and in contrast, LEARN represents the traditional, mainstream approach to dieting. So this was a two-year, head to head study of low-carb versus traditional weight loss.

We’d all probably recognize ourselves in Carmen. The book reviews Carmen’s history of trying every diet and regaining all lost weight. He is the classic yo-yo dieter. His wish comes true and he’s assigned to the Atkins diet group. And we’re off.

Chapter 2: Epiphanies and Hucksters

It turns out that nothing in the diet world is new; everything is rediscovered. This chapter traces the history of diets from the ancient Greeks, focusing on the 19th century onward. It covers the first low-carb trend, drinking vinegar for weight loss, ‘Fletcherizing’ (chewing excessively) your food, low-protein and low-calorie plans, weight loss contests a la The Biggest Loser, diet pills and even weight loss surgery. It’s a fascinating chapter if you’re intrigued by dieting through the ages. And it’s somewhat depressing given as we seem to keep doing the same things over and over again without very much in terms of long-term results.

One Month

We now jump back to the group of Penn dieters. They’re one month into their diets and it’s the honeymoon period. The group discusses how to avoid temptations – it sounds like 3FC!

Chapter 3: Oh, to Be as Thin as Jennifer Aniston (or Brad Pitt)

As the different diets came and went, our body weight ideals got smaller and smaller. What was the epitome of female attractiveness in the late 1800s was considered positively chunky by the Flapper Era of the 1920s and that ideal is considered to be downright chubby today. The trend has undeniably been toward thinner and thinner as the ideal at the same time as we as a society are getting larger and larger. "By the 1960s … the ideal female body was once again that of a preadolescent girl". (p 78)

Three technologies enabled us to make dieting our obsession: the bathroom scale, the full-length mirror, and photography. All three give us objective evidence of our size and contribute to our national weight preoccupation.

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Many people may not aspire to the extremely low weight of a Kate Moss or even a Jennifer Aniston. But nearly all who worry about their weight have a dream weight, and for many fat people, the weight becomes the weight which, they are convinced, they will be their true selves. (p 78)

Two Months

We meet two more Penn dieters: Jerry Gordon (227 pounds at 5’ 4”) and Graziella Mann (223 pounds). They’ve both been assigned to the low-calorie study group. The book reviews their personal lifetime diet struggles, sounding just like most of us here at 3FC.

Chapter 4: A Voice in the Wilderness

Now that the book has reviewed the history of dieting and the evolution of social weight ideals, we move on to the science of obesity and weight loss.

This chapter focuses on the question of whether people become fat due to emotional eating. It concludes, after reviewing numerous studies, that fat people are not more emotionally disturbed and do not suffer more emotional problems than thin people do:

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Stunkard (the voice in the wilderness) looked for, but never was able to find, evidence that psychological problems were creating obesity. The data in study after study was consistent – obese people have no unique psychiatric abnormalities. Some had problems, such as anxiety, depression, and mood disorders, but in every instance the psychiatric problems were just as prevalent in people of normal weight. (p 93)

The chapter then discusses how obesity is not considered to be a psychiatric illness, though two small subsets –- binge eating disorder and night eating -- are considered, at least provisionally, to be psychiatric disorders.

We’re left with the question:

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And so, if there is no distinctive fat person’s eating behavior, no fat person’s psychology, what does make fat people fat? And why are some people so much more successful than others in losing their excess weight and keeping it off? (p 97)

Three Months

We’re three months into the Penn study and just about everyone has lost 10% of their starting weight. This becomes an opportunity to discuss goal weights. The Penn researchers tell the study participants that a 10% loss would be a resounding success, yet all of the dieters have much greater weight loss goals. They would all consider a mere 10% loss to be a failure.

Chapter 5: A Drive to Eat

Chapter 5 begins the meat and potatoes of the book: an overview of the scientific studies concerning obesity, appetite, and weight determination. It begins with the famous World War 2 Keys starvation studies. Healthy volunteers (conscientious objectors) cut their calories in half and added in walking exercise (just like dieters do). The men lost 25% of their weight over six months time. But the consequences of the diet were -– as the book puts it –- shocking. The men became obsessed with food; thinking, dreaming, and talking about it nonstop. They began binging. They suffered psychological problems. And their metabolisms slowed to 40% of normal.

The next study discussed was conducted at Rockefeller University to determine what happened to fat cells when obese people lose weight. Four men lived at the University and lost an average of 100 pounds each over a six month period on a 600-calorie per day diet. What shocked the researchers was the fact that all regained their lost weight when they left the hospital setting.

So they:

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... repeated the experiment and repeated it again. Every time the result was the same. The weight, so painstakingly lost, came right back. But since this was a research study, the scientists looked at more than just weight loss; just as in the first study they measured metabolic changes and psychiatric conditions and body temperature and pulse. And that led them to a surprising conclusion: Fat people who lose large amounts of weight may look like someone who was never fat, but they are very different. In fact, by every measurement, they seemed like people who are starving. (p 114, emphasis added)

OK, so obese people who lose weight look psychologically and metabolically like starved people. So what about people who deliberately try to gain weight? Normal sized individuals were studied who increased their calories drastically to gain weight. This study found that they had to eat a great many more calories than would be expected from the 3500 excess calories = a pound theory because their metabolisms sped up to try to compensate for the increased caloric input.

From these studies, the book concludes:

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The implications were clear. There is a reason that fat people can’t stay thin after they diet and that thin people can’t stay fat when they force themselves to gain weight. The body’s metabolism speeds up or slows down to keep weight in a narrow range. Gain weight and metabolism can as much as double; lose weight and the metabolism can slow down to half its speed. (p 118-9)

So what determines whether one is naturally fat or thin? Researchers turned to studies of adopted children and identical twins separated at birth to determine that childhood family environment has little or no effect on weight. Almost all differences in weight can be attributed to genetic differences. Everyone has a natural weight range of 10 – 20 pounds and weight can easily be manipulated within this comfortable range but to go outside of it requires extreme effort:

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Going much above or much below a person’s natural weight range is difficult, and the body fights back by increasing or decreasing the appetite, and increasing or decreasing the metabolism to push the weight back to the range it seeks. (p 125)

Five Months

The Penn dieters are discussing temptations and willpower. The big question is how to maintain motivation and resist temptation forever.

Chapter 6: Insatiable, Voracious Appetites

Chapter 5 rounded up the studies proving that obesity is a genetically linked trait and that it’s extremely difficult to manipulate your weight outside of a preset range. Chapter 6 moves into the world of hormones, receptors, and genes. Why do we get hungry? What makes us feel full? Is this system faulty in some people?

The chapter tells the story of the ob mice (ob for obese) -- genetic mutants who ate more than other mice and grew enormous – and the search for the ob gene.

Of course, it seems irresistible to ask whether such a satiety substance underlies human obesity. Maybe some fat people are like ob mice, unable to make enough of the satiety substance, while others may be like the db mice, making plenty of the substance but failing to respond to it. Maybe there are degrees of an ability to make or respond to the substance, which is why some people are fat, some are overweight, and others are skinny. (p 139)

The chapter details the discovery of the ob gene and discusses the role of hormones and receptors in appetite control. It concludes by saying that the body exerts a tight control over weight -- your body weight is genetically programmed and will fight to stay in its predetermined range:

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People live in the moment. They lose weight in the short term and say that they’ve exercised willpower … it appears that over the long term, the basic drive wins out. As just as willpower can’t make fat people thin, a lack of it does not make thin people fat. (p 144)

The ob gene turns out to regulate the hormone leptin, discussed in great depth in chapter 7.

Six Months
We’re only six months into the two-year study but the diet honeymoon is over. Most of our study participants have stopped losing and started regaining.

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"You have to be really motivated – and we were,” (Carmen) says of himself and his fellow dieters. “For six months we did very well. But can you maintain this sort of thing? I think it’s very unrealistic. We just weren’t able to do it." (p 155)

Chapter 7: The Girl Who Had No Leptin

Chapter 7 focuses on hormones that regulate hunger and satiety, primarily leptin, though others such as ghrelin, PYY, and AgRP are also discussed. The chapter opens with the story of a child born without leptin, who had an insatiable appetite. She grew tremendously obese until she was given leptin injections, after which her appetite and size returned to normal. Researchers drew hope from her experience that leptin injections would become the key to weight control for the obese.

Unfortunately, experiments didn’t bear this simple solution out and it now appears that the leptin pathway is a complicated system with potential for disruption at many steps along the chain.

The intriguing findings about leptin are that it also seems to have the potential to reshape and rewire the brain, permanently changing a person’s weight and appetite. Perhaps there are critical times in a person’s life – perhaps in infancy? – when the brain is wired for obesity? There are tremendous implications to the ongoing research:

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Jeff Flier likens the effect of leptin on brain changes when memories are stored. The brain almost seems to be developing a memory for the weight it wanted the animal to be … “It is at the interface of free will and determinism. There is certainly a strong biological underpinning to our drive to eat and maintain certain weights. We knew that before and we still know it. But now there is another layer of mechanisms by which things like hormones not only can affect the neurochemistry that affects how hungry you are but also can affect the wiring of your brain.” (p 170)

The overwhelming lesson of chapter 7 is that the mechanisms of appetite and satiety are controlled by multiple hormones and their receptors, along complicated brain pathways. And we are only beginning to unravel the mysteries of how they work and what goes wrong in the guts and brains of the obese.

Ten Months

Ron Krauss, one of the study participants, hits his lowest weight ten months into the study and promptly begins to regain. He blames himself for getting sloppy with portion sizes, eating at night, and failing to journal.

Jerry Gordon reaches his low weight after six months and then stalled. He blames himself for not having sufficient self-discipline.

Graziella Mann reached her low weight after six months. She’s rededicating herself to the program.

Carmen Pirollo lost his willower (as he put it) after six months and started to regain.

But none of the participants is giving up; all are sticking to the study for the full two years.

Chapter 8: The Fat Wars

Chapter 8 of Rethinking Thin challenges many popular beliefs about the health hazards of excess weight. It asks why we as a nation are fixated on weight as a health crisis? Why is obesity considered to one of the top health risks, right up there with smoking? It disputes the notion that being overweight is unhealthy and can lead to premature death. It challenges the idea that we can intervene in children’s lives to reduce the incidence of obesity. And it even suggests that being overweight may confer positive and protective health benefits and lead to a longer life span:

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Could it mean that the obesity epidemic is actually a good thing, with heights increasing because of better nutrition and freedom from disease, and with weights increasing too, to allow the average person the best possible health? (p 209)

The author suggests that there are financial interests that have a stake in demonizing obesity as a huge health risk, such as researchers and businesses devoted to weight loss. Her attitude is that being overweight is not necessarily unhealthy and it's almost impossible to change it anyway, so why bother?

Two Years

We jump from ten months into the Penn study to its conclusion at the end of two years. Few of the study dieters show up for the last meeting. The Atkins mania has turned into a bust and diet trends have moved on to whole grains, low GI, low sugar, and no trans fats.

Of our four spotlight dieters, Graziella has lost 11 pounds in the two years. Jerry is still fat and says he expects to stay that way. Carmen is still obese. Ron lost a total of 30 pounds. None has come even close to reaching their dream weights. All the dieters say they’ve learned better habits that they will continue for a lifetime.

Epilogue

The book’s epilogue begins with the notion of the psychology of false hope – a belief in something despite all evidence to the contrary. The author says that she experienced it herself in writing the book:

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…what was weird was that I saw … the false hope syndrome in myself as well. I wanted Carmen and Graz, and Jerry and Ron, and all the others to succeed. I wanted it so much that I began to suspend disbelief. I knew, I knew, the science and the overwhelmingly convincing evidence that most obese people will not be able to diet, get thin, and stay at a new low weight. But …. I fell under the dieter’s spell. I allowed myself to think that maybe, just maybe, these people would make it. Maybe they would fulfill their dreams. (pp 220-221)

We already know that those four dieters didn’t even come close to reaching their goal weights and, fact, managed to lose and keep off only a small amount of weight, if any.

The author then concludes the book with an her suggestion of how we might "rethink" the issues of thinness and obesity:

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The origins of people’s recent weight gains may have little to do with their current environment or with their willower, or lack of it, or with today’s social customs to snack ad eat or the run or with any other popular belief. Instead … we may be a new, heavier human race and our weight may have been set by events that happened very early in life, maybe even prenatally.

… Maybe … something happened early in life – better nutrition, vaccines to provide freedom form viral infections that plagued children of previous generations, antibiotics to cure infections like strep throat or pneumonia – that precipitated changes in the brain’s control over weight. Maybe a woman who gets sufficient amounts of some vitamin during pregnancy will give birth to a baby with a certain configuration in the brain that leads to a bigger appetite and weight gain.

Higher weights could be the unintended consequence of the nation’s general better health, or maybe even a contributor to it. Maybe whatever is pushing up the average weights of the nation might be for the best.

I think the diet science is not developed. People come up with different theories and try to brainwash others.
I have seen different diatitians telling different theories.
But, you are succe ssful in keeping your excess weight off from 2011.
So, tell us your experience, rather than telling us disappointing theories of half baked brainy diatitians.
Parden me, but these theories really discorage people.

Having read your long post here, Meg, all I can say is that this book doesn't really shed any new information on this subject. I am inclined to believe that the reason why the population of the United States is now at 60% obese has more to do with the fact of our lifestyle choices.

Seven and a half years ago, I moved to Atlanta, Georgia from a small "walk-friendly" Midwestern town. There is a local saying here that "Atlanta is the city where you drive somewhere to go for a walk." My husband and I have found this to be true. When I lived in the aforementioned smaller college town, after our evening meal, we would put our athletic shoes on and go for an evening walk almost every night. It helped us digest our meal, relaxed us after a day at work and helped to put us to sleep. It was easy. We just stepped outside our front door. Within a year of moving here, I can gained 35 lbs and went up one size in clothing. Ditto with my former thin husband.

Although I had been diagnosed with arthritis in 1994, I never had any symptoms (ie, pain, stiffness, lack of mobility) UNTIL I moved here and stopped my regular exercise. Within 4 years, I was even bed ridden for a period of several months; due to the fact that I was inactive. I had no idea that I had kept the more serious complications of my arthritis at bay all of those previous years by doing something as simple as a nightly walk with my partner.

I stopped dieting long ago. However, what I have done is learn to make food choices that support a healthier body. As a result, the weight is coming off slowly but it is coming off. I "discovered" in January 2010 that my morning blood glucose was 174 mg/dl (diabetic is 146 mg/dl and normal is 90 mg/dl). By simply changing my food choices I have had a normal fasting blood glucose for nearly a year and my eye doctor, who was the one who first pointed out to me about the changes in my vision, now claims I have the vision of someone nearly 20 years younger! He was amazed! It goes without saying that you are what you eat.

I followed your personal history, Meg, long ago and I do know that you lost over 100 lbs in less than a year. I think that is what everyone here wishes they could do. However, after reading such books as the one you reviewed, and seeing how people here have struggled so much and feel they have gotten so little out of all their efforts; I have recently decided that I would instead focus on having good (if not great) health.

Since the affects of my RA and osteo-arthritis have really thwarted my desire to be as active as I once was, I have learned a more important lesson (for me): health and wellness is not a number on the scale nor a certain physical body image that may or may not conform to societal standards. What is to me today is to have "normal" numbers like blood glucose, blood pressure and blood cholesterol (all of mine are "normal"). The other part is that I am able to be as active as my arthritis will allow me to be. I am being more pro-active about regaining some of the muscle I lost when I moved here and with that strength and flexibility. I do set weight lose goals for myself but I don't "stress out" about not reaching a particular goal at a particular time. I do think that the obsessing that often accompanies weight lose efforts is counter-productive and can even contribute to a lack of overall well being. Will I end up seeing my goal weight? I honestly don't know at this point but, in the meantime, I am learning that optimal health is more subjective than being able to do 100 ab crunches or walking 10,000 steps a day. To me, that is real hope and one I am willing to bank on.

I imagine the rethinking thin info is accurate if our expectations are unrealistic and you expect to go back to relying on your genes to eat high tech food. But we know thousands of people can and do lose weight and keep it off.

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